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Although procedural sedation for cardioversion is a common event in emergency departments (EDs), there is limited evidence surrounding medication choices. We sought to evaluate geographic and temporal variation in sedative choice at multiple Canadian sites, and to estimate the risk of adverse events due to sedative choice.
This is a secondary analysis of one health records review, the Recent Onset Atrial Fibrillation or Flutter-0 (RAFF-0 [n=420, 2008]) and one prospective cohort study, the Recent Onset Atrial Fibrillation or Flutter-1 (RAFF-1 [n=565, 2010 – 2012]) at eight and six Canadian EDs, respectively. Sedative choices within and among EDs were quantified, and the risk of adverse events was examined with adjusted and unadjusted comparisons of sedative regimes.
In RAFF-0 and RAFF-1, the combination of propofol and fentanyl was most popular (63.8% and 52.7%) followed by propofol alone (27.9% and 37.3%). There were substantially more adverse events in the RAFF-0 data set (13.5%) versus RAFF-1 (3.3%). In both data sets, the combination of propofol/fentanyl was not associated with increased adverse event risk compared to propofol alone.
There is marked variability in procedural sedation medication choice for a direct current cardioversion in Canadian EDs, with increased use of propofol alone as a sedation agent over time. The risk of adverse events from procedural sedation during cardioversion is low but not insignificant. We did not identify an increased risk of adverse events with the addition of fentanyl as an adjunctive analgesic to propofol.
We sought to conduct a major objective of the CAEP Academic Section, an environmental scan of the academic emergency medicine programs across the 17 Canadian medical schools.
We developed an 84-question questionnaire, which was distributed to academic heads. The responses were validated by phone by the lead author to ensure that the questions were answered completely and consistently. Details of pediatric emergency medicine units were excluded from the scan.
At eight of 17 universities, emergency medicine has full departmental status and at two it has no official academic status. Canadian academic emergency medicine is practiced at 46 major teaching hospitals and 13 specialized pediatric hospitals. Another 69 Canadian hospital EDs regularly take clinical clerks and emergency medicine residents. There are 31 full professors of emergency medicine in Canada. Teaching programs are strong with clerkships offered at 16/17 universities, CCFP(EM) programs at 17/17, and RCPSC residency programs at 14/17. Fourteen sites have at least one physician with a Master’s degree in education. There are 55 clinical researchers with salary support at 13 universities. Sixteen sites have published peer-reviewed papers in the past five years, ranging from four to 235 per site. Annual budgets range from $200,000 to $5,900,000.
This comprehensive review of academic activities in emergency medicine across Canada identifies areas of strengths as well as opportunities for improvement. CAEP and the Academic Section hope we can ultimately improve ED patient care by sharing best academic practices and becoming better teachers, educators, and researchers.
The ngwayir (western ringtail possum Pseudocheirus occidentalis) is an arboreal species endemic to south-western Australia. The range and population of this species have been significantly reduced through multiple anthropogenic impacts. Classified as vulnerable, the ngwayir is highly susceptible to extremes of temperature and reduced water intake. Ngwayir distribution was determined using three different species distribution models using ngwayir presence records related to a set of 19 bioclimatic variables derived from historical climate data, overlaid with 2050 climate change scenarios. MaxEnt was used to identify core habitat and demonstrate how this habitat may be impacted. A supplementary modelling exercise was also conducted to ascertain potential impacts on the tree species that are core habitat for ngwayir. All models predicted a reduction of up to 60% in the range of the ngwayir and its habitat, as a result of global warming towards the south-west of the project area, with a mean potential distribution of 10.3% of the total modelled area of 561 059 km2. All three tree species modelled (jarrah, marri and peppermint) were predicted to experience similar contractions in range throughout most of the predicted ngwayir range, although their distributions differed. Populations of ngwayir persisting outside core habitat may indicate potential conservation opportunities.
It is believed that when patients present to the emergency department (ED) with recent-onset atrial fibrillation or flutter (RAFF), controlling the ventricular rate before cardioversion improves the success rate. We evaluated the influence of rate control medication and other variables on the success of cardioversion.
This secondary analysis of a medical records review comprised 1,068 patients with RAFF who presented to eight Canadian EDs over 12 months. Univariate analysis was performed to find associations between predictors of conversion to sinus rhythm including use of rate control, rhythm control, and other variables. Predictive variables were incorporated into the multivariate model to calculate adjusted odds ratios (ORs) associated with successful cardioversion.
A total of 634 patients underwent attempted cardioversion: 428 electrical, 354 chemical, and 148 both. Adjusted ORs for factors associated with successful electrical cardioversion were use of rate control medication, 0.39 (95% confidence interval [CI] 0.21-0.74); rhythm control medication, 0.28 (95% CI 0.15-0.53); and CHADS2 score > 0, 0.43 (95% CI 0.15-0.83). ORs for factors associated with successful chemical cardioversion were use of rate control medication, 1.29 (95% CI 0.82-2.03); female sex, 2.37 (95% CI 1.50-3.72); and use of procainamide, 2.32 (95% CI 1.43-3.74).
We demonstrated reduced successful electrical cardioversion of RAFF when patients were pretreated with either rate or rhythm control medication. Although rate control medication was not associated with increased success of chemical cardioversion, use of procainamide was. Slowing the ventricular rate prior to cardioversion should be avoided.
In this paper, fired and non-fired direct PECVD deposited Si-SiNx interface properties with and without NH3 pretreatment on both n- and p-type mono-crystalline silicon samples were investigated with deep-level transient spectroscopy (DLTS) measurements. A and B defect states are identified at the Si-SiNx interface. Energy-dependent electron and hole capture cross sections were measured by small-pulse DLTS. Fired samples with NH3 pretreatment show the lowest DLTS signals, which suggests the lowest overall Dit. The combination of NH3 pretreatment and firing is also suggested for application in the solar cell fabrication.
Silicon carbide (SiC) is rapidly becoming the substrate of choice for the development of high frequency and high power electronic devices employing the III-V nitride family of materials. This heteroepitaxial growth system continues to receive considerable attention, as materials issues remain the fundamental limiters to device performance. The heteroepitaxial growth of gallium nitride (GaN) thin films on stepped and step-free 4H SiC surfaces is reported. Step-free SiC surfaces are created by mesa patterning of a SiC wafer and subsequent epitaxial growth in a process described previously. This process results in a collection of both step-free and stepped surfaces on a given sample. We have employed an established metalorganic chemical vapor deposition process to grow first a thin (1200Å) aluminum nitride (AlN) nucleation layer and then a 2 μm thick GaN thin film. We have interrupted growth at various stages of AlN and GaN growth to evaluate the growth evolution using atomic force microscopy (AFM). The results show marked differences in the manner in which the initial AlN layer deposits. Nucleation is random with elongated grains on step-free SiC surfaces, while stepped surfaces have round nuclei of uniform dimensions and a high degree of spatial correlation with the nuclei arranged in rows. These differences diminish as the AlN layer approaches the desired thickness. Growth of the GaN epilayer is also markedly different on the two types of surfaces with step-free surfaces leading to random and low density nucleation of crystallites that remain as single grains for long growth times, whereas the stepped surfaces have large numbers nuclei that rapidly grow laterally. Cross-sectional transmission electron microscopy (TEM) reveals that grain sizes are 2–3X larger on step-free surfaces.
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